CardioBuzz: Should All Young Athletes Get ECGs?

When a seemingly healthy young athlete suddenly drops dead while playing sports, it's tragic and hard to accept. And it might seem like the right thing to do to avoid that scenario is to screen all young athletes with an electrocardiogram (ECG) to discover problems hiding within the heart.

The controversy was evident in the results of a poll conducted during a debate session at the American Heart Association meeting last year, which were published this week in the New England Journal of Medicine by James Colbert, MD, of Harvard Medical School.

Of the audience members who voted -- an unscientific sample, to be sure -- 70% favored some type of screening for cardiac disease in young athletes. And in a scenario where screening was already a foregone conclusion, 60% said it should include an ECG.

A similar online poll on the NEJM website was even more informative, showing that the differences in opinion exist on both sides of the Atlantic.

Of the 1,266 people who voted on the site -- again, not a scientific sample -- 18% didn't want any mandatory screening, 24% wanted screening with a medical history and physical exam, and 58% favored screening that included an ECG.

The percentage of voters who endorsed an ECG was higher among Europeans than among Americans (66% versus 45%), but that still indicates a substantial amount of controversy regardless of geography.

The largest European voting block came from Italy -- which already has a comprehensive national screening program that includes an ECG -- and those voters overwhelmingly favored what they were already doing, with 74% endorsing an ECG screen.

"There's no methodology or any scientific rigor to the actual polling process, so you have to take the results with a grain of salt," Colbert told MedPage Today.

What the results can tell us, however, is that there is a lot of disagreement about the right thing to do, which begs the question, "Why?" And there's not an easy answer.

"An important limitation of this study is that it compared data from the 2 years preceding implementation of the screening program with data from the subsequent 2 decades with no controlled comparison of screening versus nonscreening in athletes," Anne Curtis, MD, and Mohamed Bourji, MD, of the University at Buffalo in New York, wrote in an editorial published last week in the Journal of the American College of Cardiology.

The lack of randomized data showing that ECG screening cuts deaths is one of the reasons that American authorities have been hesitant to recommend adding an ECG -- as a matter of routine -- to preparticipation screening, Colbert said.

But there are other factors at play, too, including a high number of false-positives, which could lead to unnecessary testing, and the costs and logistics of setting up such an extensive system in the U.S. Two major problems, Colbert pointed out, would be finding physicians qualified to interpret all of the ECGs and finding someone to pay for them.

"A large population preparticipation screening initiative for U.S. athletes that mandates a 12-lead ECG, such as that proposed by the ESC and International Olympic Committee, is probably impractical and would require considerable resources that do not currently exist, as well as substantial long-term federal government subsidization," the AHA noted in its scientific statement.

And another issue, Colbert said, is that it's not clear what you'd tell young people with detected abnormalities. Would you tell them to avoid sports or any type of physical exertion for the rest of their lives?

"There is a lot of emotion around having a young 18-year-old athlete suddenly drop dead, and it's certainly devastating to friends, to coaches, to fellow athletes. So we'd love to prevent that, but at the same time the numbers of individuals who do drop dead or experience a sudden cardiac arrest is still quite small compared with other medical issues or public health issues that face young adults and teenagers," he said, pointing to gun violence, suicide, drug abuse, and car crashes.

"In my review of the evidence," Colbert said, "I don't think that the data support doing nationwide screening in the U.S. with an ECG."

Curtis and Bourji agreed in their editorial.

"Despite the tragedy of losing even one young individual to sudden cardiac death, mass ECG screening programs prior to sports participation, especially in recreational athletes, are neither cost-effective nor sustainable," they wrote. "The most common finding by far turns out to be a false-positive leading to additional testing before most individuals are found to be normal and cleared to exercise. The best way to avoid that scenario is not to screen with ECGs in the first place."

CardioBuzz is a blog by Todd Neale for readers with an interest in cardiology.

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